Improving the Survivorship of Older Adults with Cancer Using Geriatric Assessment

Improving the Survivorship of Older Adults with Cancer Using Geriatric Assessment Deborah Bacon, RN,BSN Geriatric Oncology Clinical Nurse Coordinator James P Wilmot Cancer Institute

Outline Geriatric assessment in oncology What is known Gaps in knowledge Examples of why geriatric domains are important to consider for the older survivor of cancer Evaluating and improving outcomes of older survivors of cancer using GA

Estimated Number of Persons Alive in the U.S. Who Were Diagnosed With Cancer, by Years Since Diagnosis (as of Jan. 1, 2012) (Invasive/1st Primary Cases Only, N = 13.7 M survivors) 0-19 Years 1% 80+ Years 20% 20-29 Years 1% 30-39 Years 3% 40-49 Years 7% 50-59 Years 17% 70-79 Years 25% 60-69 Years 26% Estimations and modeling provided by Angela Mariotto, PhD, based on: Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28. Epub 2011 Jan 12.

Important Considerations for Older Cancer Patients

Incorporation of Geriatric Assessment (GA) into Oncology Clinical Care GA is an approach to the evaluation of the older patient Includes an evaluation of the following domains: - functional status - objective physical performance - comorbid medical conditions - cognition - nutritional status - psychological status - social support - geriatric syndromes Each domain is an independent predictor of morbidity and mortality in the older patient

Short Physical Performance Battery Developed at the NIA for the Established Population for the Epidemiologic Studies of the Elderly (EPESE) Timed standing balance (up to 10 seconds) Side-by-side stand Semi-tandem stand Tandem stand Timed 4-meter walk Chair rise Single Timed multiple (5) chair rises TOTAL TIME TO COMPLETE ~ 2 MINUTES CAN BE GIVEN BY A TRAINED ASSISTANT IN THE HALL. REQUIRES ONLY ARMLESS CHAIR & STOP WATCH OR SECOND HAND SWEEP WATCH

Disability Status at 4 Year Follow-up by SPPB Baseline Summary Score Among Those Not Disabled at Baseline Iowa EPESE Percent 100 80 60 40 Non- Disabled Mobility Disabled ADL + Mobility Disabled 20 0 4 5 6 7 8 9 10 11 12 ADL = activity of daily living Guralnik JM, et al. N Engl J Med. 1995;332:556-561. Summary Performance Score

Nursing Home Admission Rates by SPPB Summary Score Age and Sex Adjusted Nursing Home Admissions per 100 Person Years 25 20 15 10 5 0 22.5 19.6 17.5 12.8 11.6 10.2 7.2 6.0 4.6 4.8 2.7 0.8 0.7 0 1 2 3 4 5 6 7 8 9 10 11 12 Performance Test Summary Score Guralnik JM, et al. J Gerontol Med Sci. 1994;49:M85-M94.

Relationship of Frailty to Health Outcomes Fried et al. Journal of Gerontology; 59: 255-263 Having 3 or more: Weight Loss Exhaustion Low Physical Activity Slow Walk Time Poor Grip Strength Outcome Worsening mobility disability Worsening ADL disability Hazard Ratios over 3 years 1.50 1.98 Incident fall 1.29 First hospitalization 1.29 Death 2.24

A High Prevalence in Older Patients with a History of Cancer Mohile et al. JNCI; September 2009

Impact of Geriatric Syndromes on Survival in Patients with Colon Cancer Geriatric Syndromes and Mortality -One syndrome HR=1.18 (0.99-1.41) -Two syndromes HR=2.34 (1.74-3.15) Koroukian et al. J Gerontology Med Science, 2009

Considerations Can we identify those older patients who are at high risk of acute toxicity? What is the long-term impact of therapy on underlying health? Survivorship issues in those with more limited life expectancy due to age and/or health

Treatment Tolerance and Mortality in Breast Cancer Patients by GA Deficits Clough-Gorr, K. M. et al. J Clin Oncol; 28:380-386 2010

GA Variables Predict Chemotherapy Toxicity in Older Adults Risk factors for Gr. 3-5 Toxicity OR (95% CI) Score Age 73 yrs 1.8 (1.2-2.7) 2 GI/GU cancer 2.2 (1.4-3.3) 3 Standard dose 2.1 (1.3-3.5) 3 Poly-chemotherapy 1.8 (1.1-2.7) 2 Hemoglobin (male: <11, female: <10) 2.2 (1.1-4.3) 3 Creatinine Clearance (Jelliffe ideal wt) <34 2.5 (1.2-5.6) 3 1 or more falls in last 6 months 2.3 (1.3-3.9) 3 Hearing impairment (fair or worse) 1.6 (1.0-2.6) 2 Limited in walking 1 block (MOS) 1.8 (1.1-3.1) 2 Assistance required in medication intake 1.4 (0.6-3.1) 1 Decreased social activity (MOS) 1.3 (0.9-2.0) 1 Hurria and CARG, JCO 2011 Possible score range: 0-25

Considerations Can we identify those older patients who are at high risk of acute toxicity? What is the long-term impact of therapy on underlying health? Survivorship issues in those with more limited life expectancy due to age and/or health

30% of older patients fall each year Increases to 50% after age 80 10% have injury Prevention Exercise (balance, strength, endurance) Environmental Address vision issues Reduce psychoactive meds Falls Mohile et al. JCO, 2011, p<.001

Falls in patients with CIPN Tofthagen et al. Support Care Cancer, 2011 20% of patient with CIPN fall (21/109) Fallers: received higher doses of chemotherapy were more likely to receive taxanechemotherapy have more neuropathic symptoms report more interference of CIPN with function have a higher interference with walking and driving

Association of motor neuropathy toxicity with falls, physical performance problems, and functional losses 1.5 1.45 1.4 ODDS Ratio 1.35 1.3 1.25 1.2 1.15 1.1 1.05 1 Falls Physical performance problems Functional Losses Gewantder. Supportive Care Cancer, 2013

ADT and Frailty Bylow et al. Cancer, 2007

Geriatric Oncology Priorities We know that GA can help: Identify patients at most risk for toxicity Now, we need to try to improve outcomes Incorporate GA into clinical trials for older adults Educate providers Develop recommendations from GA to help older patients with cancer

Using GA to Guide Interventions

Priorities for the Older Survivor of Cancer with CIPN? Utilize standardized outcomes for mobility, balance, and function Measure the impact of balance and mobility training Evaluate and intervene on fall risk Assist device Home safety evaluation and modification Assess health care utilization Include in survivorship care plans Adapted from Hile, Phys Therapy, 2010

Participants: Geriatric Oncologist Clinic Coordinator RN (oncology and geriatrics training) PT OT (additional cognitive training) Social Work Fellows/residents/med students Pharmacist Palliative Care Nutritionist SOCARE Clinic

Conclusions The numbers of elderly patients with cancer are growing An assessment of an older cancer patient s life expectancy, reserve, comorbidity, and function may help predict risk of toxicity or poor outcome A geriatric assessment can help identify which older patients will benefit from geriatric interventions to improve survivorship